SB40: Drafts

b. A child who is eligible under sub. (4) (a) 2. or (b) 2.

c. A child whose family income does not exceed 200 percent of the poverty line.

d. A pregnant woman whose family income does not exceed 200 percent of the poverty line.

e. A child who obtains eligibility under sub. (7) (b) 2.

f. An individual who is eligible under sub. (4) (a) 5.

5. If a recipient who is required to pay a premium under this paragraph or under sub. (4) (c) does not pay a premium when due, the recipient's coverage terminates and the recipient is not eligible for BadgerCare Plus for 6 calendar months following the date on which the recipient's coverage terminated.

(11) BENCHMARK PLAN BENEFITS AND COPAYMENTS. Recipients who are not eligible for the benefits described in s. 49.46 (2) (a) and (b) shall have coverage of the following benefits and pay the following copayments:

(a) Subject to sub. (6) (k), prescription drugs bearing only a generic name, as defined in s. 450.12 (1) (b), with a copayment of no more than $5 per prescription, and subject to the Badger Rx Gold program discounts.

(b) Physicians' services, including one annual routine physical examination, with a copayment of no more than $15 per visit.

(c) Inpatient hospital services as medically necessary, subject to coinsurance payment per inpatient stay of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided and a copayment of no more than $50 per admission for psychiatric services.

(d) Outpatient hospital services, subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided, except that use of emergency room services for treatment of a condition that is not an emergency medical condition, as defined in s. 632.85 (1) (a), shall require a copayment of no more than $75.

(e) Laboratory and X-ray services, including mammography.

(f) Home health services, limited to 60 visits per year.

(g) Skilled nursing home services, limited to 30 days per year, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.

(h) Inpatient rehabilitation services, limited to 60 days per year, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.

(i) Physical, occupational, speech, and pulmonary therapy, limited to 20 visits per year for each type of therapy, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.

(j) Cardiac rehabilitation, limited to 36 visits per year and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.

(k) Inpatient, outpatient, and transitional treatment for nervous or mental disorders and alcoholism and other drug abuse problems, with a copayment of no more than $15 per visit and coverage limits that are the same as those under the state employee health plan under s. 40.51 (6).

(L) Durable medical equipment, limited to $2,500 per year, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the articles provided.

(m) Transportation to obtain emergency medical care only, as medically necessary, and subject to coinsurance payment of no more than 10 percent of the allowable payment rates under s. 49.46 (2) for the services provided.

(n) One refractive eye examination every 2 years, with a copayment of no more than $15 per visit.

(o) Fifty percent of allowable charges for preventive and basic dental services, including services for accidental injury and for the diagnosis and treatment of temporomandibular disorders. The coverage under this paragraph is limited to $750 per year, applies only to pregnant women and children under 19 years of age, and requires an annual deductible of $200 and a copayment of no more than $15 per visit.

(p) Early childhood developmental services, for children under 6 years of age.

(q) Smoking cessation treatment, for pregnant women only.

(r) Prenatal care coordination, for pregnant women at high risk only.

(11m) PROVIDER PAYMENTS AND REQUIREMENTS. The provider of a service or equipment under sub. (11) shall collect the specified or allowable copayment or coinsurance, unless the provider determines that the cost of collecting the copayment or coinsurance exceeds the amount to be collected. The department shall reduce payments for services or equipment under sub. (11) by the amount of the specified or allowable copayment or coinsurance. A provider may deny care or services or equipment under sub. (11) if the recipient does not pay the specified or allowable copayment or coinsurance. If a provider provides care or services or equipment under sub. (11) to a recipient who is unable to share costs as specified in sub. (11), the recipient is not relieved of liability for those costs.

(12) RULES; NOTICE OF EFFECTIVE DATE. (a) 1. The department may promulgate any rules necessary for and consistent with its administrative responsibilities under this section, including additional eligibility criteria.

2. The department may promulgate emergency rules under s. 227.24 for the administration of this section for the period before the effective date of any permanent rules promulgated under subd. 1., but not to exceed the period authorized under s. 227.24 (1) (c) and (2). Notwithstanding s. 227.24 (1) (a), (2) (b), and (3), the department is not required to provide evidence that promulgating a rule under this subdivision as an emergency rule is necessary for the preservation of the public peace, health, safety, or welfare and is not required to provide a finding of emergency for a rule promulgated under this subdivision.

(b) If the amendments to the state plan submitted under sub. (2) are approved and a waiver that is consistent with all of the provisions of this section is granted and in effect, the department shall publish a notice in the Wisconsin Administrative Register that states the date on which BadgerCare Plus is implemented.

SECTION 57. 49.473 (2) (a) of the statutes is amended to read:

49.473 (2) (a) The woman is not eligible for medical assistance under ss. 49.46 (1) and (1m), 49.465, 49.468, 49.47, 49.471, and 49.472, and is not eligible for health care coverage under s. 49.665.

SECTION 58. 49.49 (3m) (a) (intro.) of the statutes is amended to read:

49.49 (3m) (a) (intro.) No provider may knowingly impose upon a recipient charges in addition to payments received for services under ss. 49.45 to 49.47 49.471 or knowingly impose direct charges upon a recipient in lieu of obtaining payment under ss. 49.45 to 49.47 49.471 except under the following conditions:

SECTION 59. 49.49 (3m) (a) 1. of the statutes is amended to read:

49.49 (3m) (a) 1. Benefits or services are not provided under s. 49.46 (2) or 49.471 (11) and the recipient is advised of this fact prior to receiving the service.

SECTION 60. 49.49 (3m) (a) 2. of the statutes, as affected by 2007 Wisconsin Act .... (this act), is amended to read:

49.49 (3m) (a) 2. If an applicant is determined to be eligible retroactively under s. 49.46 (1) (b) or, 49.47 (4) (d), or 49.471 and a provider bills the applicant directly for services and benefits rendered during the retroactive period, the provider shall, upon notification of the applicant's retroactive eligibility, submit claims for payment under s. 49.45 for covered services or benefits rendered to the recipient during the retroactive period. Upon receipt of payment under s. 49.45, the provider shall reimburse the recipient or other person who has made prior payment to the provider for services provided to the recipient during the retroactive eligibility period, by the amount of the prior payment made.

****NOTE: This is reconciled s. 49.49 (3m) (a) 2. This SECTION has been affected by LRB-0250 and LRB-0905.

SECTION 61. 49.49 (3m) (a) 3. of the statutes is amended to read:

49.49 (3m) (a) 3. Benefits or services for which recipient copayment, coinsurance, or deductible is required under s. 49.45 (18), not to exceed maximum amounts allowable under 42 CFR 447.53 to 447.58, or for which recipient copayment or coinsurance is required under s. 49.471 (11).

SECTION 62. 49.497 (title) of the statutes is amended to read:

49.497 (title) Recovery of incorrect Medical Assistance or Badger Care payments and of unpaid employer penalties.

SECTION 63. 49.497 (1r) of the statutes is created to read:

49.497 (1r) (a) The department may recover any penalty assessment not paid under s. 49.471 (9) (c) from the employer against which the penalty was assessed. If, after notice that payment of a penalty is overdue, the employer who is liable fails to pay the penalty amount, or enter into or comply with an agreement for payment, the department may bring an action to enforce the liability or may issue an order to compel payment of the liability. Any person aggrieved by an order issued by the department under this paragraph may appeal the order as a contested case under ch. 227 by filing with the department a request for a hearing within 30 days after the date of the order. The only issue at the hearing shall be the determination by the department that the person has not paid the penalty or entered into, or complied with, an agreement for payment.

(b) If any employer named in an order to compel payment issued under par. (a) fails to pay the department any amount due under the terms of the order and no contested case to review the order is pending and the time for filing for a contested case review has expired, the department may present a certified copy of the order to the circuit court for any county. The sworn statement of the secretary shall be evidence of the failure to pay the penalty. The circuit court shall, without notice, render judgment in accordance with the order. A judgment rendered under this paragraph shall have the same effect and shall be entered in the judgment and lien docket and may be enforced in the same manner as if the judgment had been rendered in an action tried and determined by the circuit court.

(c) The recovery procedure under this subsection is in addition to any other recovery procedure authorized by law.

SECTION 64. 49.497 (4) of the statutes is amended to read:

49.497 (4) The department may appear for the state in any and all collection matters under this section, and may commence suit in the name of the department to recover an incorrect payment from the recipient to whom or on whose behalf it was made or to recover an unpaid penalty from the employer against which the penalty was assessed.

SECTION 65. 49.665 (4) (ap) 2. of the statutes is repealed.

SECTION 66. 49.665 (7) (a) 1. of the statutes is amended to read:

49.665 (7) (a) 1. Notwithstanding sub. (4) (a) 3m. and (ap) 2., the department shall mail information verification forms to the employers of the individuals required to provide the verifications under sub. (4) (a) 3m. and (ap) 2. to obtain the information specified.

SECTION 67. 49.688 (5) (a) (intro.) of the statutes is amended to read:

49.688 (5) (a) (intro.) Beginning on September 1, 2002, except as provided in sub. (7) (b), as a condition of participation by a pharmacy or pharmacist in the program under s. 49.45, 49.46, or 49.47, or 49.471, the pharmacy or pharmacist may not charge a person who presents a valid prescription order and a card indicating that he or she meets eligibility requirements under sub. (2) an amount for a prescription drug under the order that exceeds the following:

SECTION 68. 49.785 (1) (intro.) of the statutes is amended to read:

49.785 (1) (intro.) Except as provided in sub. (1m), if any recipient of benefits under s. 49.148, 49.46 or 49.77, or under 42 USC 1381 to 1385 in effect on May 8, 1980, specified in sub. (1c) dies and the estate of the deceased recipient is insufficient to pay the funeral, burial, and cemetery expenses of the deceased recipient, the county or applicable tribal governing body or organization responsible for burial of the recipient shall pay, to the person designated by the county department under s. 46.215, 46.22, or 46.23 or applicable tribal governing body or organization responsible for the burial of the recipient, all of the following:

SECTION 69. 49.785 (1c) of the statutes is created to read:

49.785 (1c) All of the following are eligible recipients under this section:

(a) A recipient of benefits under s. 49.148, 49.46, or 49.77, or under 42 USC 1381 to 1385 in effect on May 8, 1980.

(b) A recipient of benefits under s. 49.471 who is any of the following:

1. A pregnant woman or a child under 6 years of age with a family income not exceeding 185 percent of the poverty line at the time of death.

2. A child at least 6 years of age but less than 19 years of age with a family income not exceeding 100 percent of the poverty line at the time of death.

3. A parent or caretaker relative with a family income not exceeding 50 percent of the poverty line at the time of death.

SECTION 70. 49.81 (4) of the statutes is amended to read:

49.81 (4) The right to a speedy determination of the recipient's status or eligibility for public assistance, to notice of any proposed change in such status or eligibility, and, in the case of assistance granted under s. 49.19, 49.46, 49.468 or, 49.47, or 49.471, to a speedy appeals process for resolving contested determinations.

SECTION 71. 49.82 (2) (b) 1. of the statutes, as created by 2007 Wisconsin Act .... (this act), is amended to read:

49.82 (2) (b) 1. A child who is eligible for medical assistance under s. 49.46 or, 49.47, or 49.471 because of 42 USC 1396a (e) (4).

****NOTE: This is reconciled s. 49.82 (2) (b) 1. This SECTION has been affected by drafts with the following LRB numbers: LRB-0905 and LRB-1311.

SECTION 72. 49.82 (2) (b) 2. of the statutes, as created by 2007 Wisconsin Act .... (this act), is amended to read:

49.82 (2) (b) 2. An unborn child who is eligible for coverage under s. 49.471 or the Badger Care health care program under s. 49.665 (4) (ap).

****NOTE: This is reconciled s. 49.82 (2) (b) 2. This SECTION has been affected by drafts with the following LRB numbers: LRB-0905 and LRB-1311.

SECTION 73. 49.84 (6) (c) 1. d. of the statutes, as created by 2007 Wisconsin Act .... (this act), is amended to read:

49.84 (6) (c) 1. d. A child who is receiving medical assistance under s. 49.46 (1) (a) 13. or, 49.47 (4) (am) 3., or 49.471 (4) (a) 2. or (b) 2. or an unborn child receiving prenatal care under s. 49.471.

****NOTE: This is reconciled s. 49.84 (6) (c) 1. d. This SECTION has been affected by drafts with the following LRB numbers: -0265 and -0905.

SECTION 74. 49.84 (6) (c) 1. e. of the statutes, as created by 2007 Wisconsin Act .... (this act), is amended to read:

49.84 (6) (c) 1. e. A pregnant woman who is receiving medical assistance under s. 49.465 or a child or pregnant woman who is receiving medical assistance under s. 49.471 (5) (b) 1. or 2.

****NOTE: This is reconciled s. 49.84 (6) (c) 1. e. This SECTION has been affected by drafts with the following LRB numbers: -0265 and -0905.

SECTION 75. 49.89 (7) (b) of the statutes is amended to read:

49.89 (7) (b) The incentive payment shall be an amount equal to 15% of the amount recovered because of benefits paid under s. 49.46, 49.465, 49.468 or, 49.47, or 49.471. The incentive payment shall be taken from the federal share of the sum recovered as provided under 42 CFR 433.153 and 433.154.

SECTION 76. 51.038 of the statutes is amended to read:

51.038 Outpatient mental health clinic certification. Except as provided in s. 51.032, if a facility that provides mental health services on an outpatient basis holds current accreditation from the council on accreditation of services for families and children, the department may accept evidence of this accreditation as equivalent to the standards established by the department, for the purpose of certifying the facility for the receipt of funds for services provided as a benefit to a medical assistance recipient under s. 49.46 (2) (b) 6. f. or 49.471 (11) (k), a community aids funding recipient under s. 51.423 (2) or as mandated coverage under s. 632.89.

SECTION 77. 51.04 of the statutes is amended to read:

51.04 Treatment facility certification. Except as provided in s. 51.032, any treatment facility may apply to the department for certification of the facility for the receipt of funds for services provided as a benefit to a medical assistance recipient under s. 49.46 (2) (b) 6. f. or 49.471 (11) (k) or to a community aids funding recipient under s. 51.423 (2) or provided as mandated coverage under s. 632.89. The department shall annually charge a fee for each certification.

SECTION 78. 59.53 (5) (a) of the statutes, as affected by 2007 Wisconsin Act .... (this act), is amended to read:

59.53 (5) (a) The board shall contract with the department of children and families to implement and administer the child and spousal support and establishment of paternity and the medical support liability programs provided for by Title IV of the federal social security act. The board may designate by board resolution any office, officer, board, department or agency, except the clerk of circuit court, as the county child support agency. The board or county child support agency shall implement and administer the programs in accordance with the contract with the department of children and families. The attorneys responsible for support enforcement under sub. (6) (a), circuit court commissioners and all other county officials shall cooperate with the county and the department of children and families as necessary to provide the services required under the programs. The county shall charge the fee established by the department of children and families under s. 49.22 for services provided under this paragraph to persons not receiving benefits under s. 49.148 or 49.155 or assistance under s. 48.645, 49.19, or 49.46, 49.465, 49.47, 49.471, or 49.472.

****NOTE: This is reconciled s. 59.53 (5) (a). This SECTION has been affected by drafts with the following LRB numbers: LRB-0905 and LRB-1261.

SECTION 79. 66.0137 (3) of the statutes is amended to read:

66.0137 (3) HEALTH INSURANCE FOR UNEMPLOYED PERSONS. Any city, village, town, or county may purchase health or dental insurance for unemployed persons residing in the city, village, town, or county who are not eligible for medical assistance under s. 49.46, 49.468 or, 49.47, or 49.471 (4) (a) or (b).

SECTION 80. 227.01 (13) (um) of the statutes is amended to read:

227.01 (13) (um) Lists over-the-counter drugs covered by medical assistance Medical Assistance under s. 49.46 (2) (b) 6. i. or 49.471 (11) (a).

SECTION 81. 253.10 (3) (d) 1. of the statutes is amended to read:

253.10 (3) (d) 1. Geographically indexed materials that are designed to inform a woman about public and private agencies, including adoption agencies, and services that are available to provide information on family planning, as defined in s. 253.07 (1) (a), including natural family planning information, to provide ultrasound imaging services, to assist her if she has received a diagnosis that her unborn child has a disability or if her pregnancy is the result of sexual assault or incest and to assist her through pregnancy, upon childbirth and while the child is dependent. The materials shall include a comprehensive list of the agencies available, a description of the services that they offer and a description of the manner in which they may be contacted, including telephone numbers and addresses, or, at the option of the department, the materials shall include a toll-free, 24-hour telephone number that may be called to obtain an oral listing of available agencies and services in the locality of the caller and a description of the services that the agencies offer and the manner in which they may be contacted. The materials shall provide information on the availability of governmentally funded programs that serve pregnant women and children. Services identified for the woman shall include medical assistance for pregnant women and children under s. 49.47 (4) (am) and 49.471, the availability of family or medical leave under s. 103.10, the Wisconsin works program under ss. 49.141 to 49.161, child care services, child support laws and programs and the credit for expenses for household and dependent care and services necessary for gainful employment under section 21 of the internal revenue code. The materials shall state that it is unlawful to perform an abortion for which consent has been coerced, that any physician who performs or induces an abortion without obtaining the woman's voluntary and informed consent is liable to her for damages in a civil action and is subject to a civil penalty, that the father of a child is liable for assistance in the support of the child, even in instances in which the father has offered to pay for an abortion, and that adoptive parents may pay the costs of prenatal care, childbirth and neonatal care. The materials shall include information, for a woman whose pregnancy is the result of sexual assault or incest, on legal protections available to the woman and her child if she wishes to oppose establishment of paternity or to terminate the father's parental rights. The materials shall state that fetal ultrasound imaging and auscultation of fetal heart tone services are obtainable by pregnant women who wish to use them and shall describe the services.

SECTION 82. 302.38 (3) of the statutes is amended to read:

302.38 (3) The maximum amount that a governmental unit may pay for the costs of medical or hospital care under this section is limited for that care to the amount payable by medical assistance under subch. IV of ch. 49, except s. excluding ss. 49.468 and 49.471 (11), for care for which a medical assistance rate exists. No provider of medical or hospital care may bill a prisoner under sub. (1) for the cost of care exceeding the amount paid under this subsection by the governmental unit. If no medical assistance rate exists for the care provided, there is no limitation under this subsection.

SECTION 83. 302.386 (1) of the statutes is amended to read:

302.386 (1) Except as provided in sub. (5), liability for medical and dental services furnished to residents housed in prisons identified in s. 302.01, in a juvenile correctional facility, or in a secured residential care center for children and youth, or to forensic patients in state institutions for those services that are not provided by employees of the department shall be limited to the amounts payable under ss. 49.43 to 49.47, except s. 49.471, excluding ss. 49.468 and 49.471 (11), for similar services. The department may waive any such limit if it determines that needed services cannot be obtained for the applicable amount. No provider of services may bill the resident or patient for the cost of services exceeding the amount of the liability under this subsection.